History Form

To protect your privacy, the form below will not be submitted over the internet.
If you would like to use this form to simplify input and save
some time when you come into our office, you must have a printer.
Once printed, please bring this form with you on your next visit to our office.

Patient History Form
NOTE: This is a confidential record and will be kept in our office. Information contained here will not be released to anyone without your authorization.
Personal Information
Name:
Date of Birth:
Social Security Number:
Referring Physician:
Marital Status:	Single Married Divorced Widowed
Occupation:
Today's Visit What is the reason you are here today? (Please describe your problem in detail):

Medical History (Check all that apply and please list any others)
Asthma	Cancer	Thyroid Disorder	Stroke
Diabetes	Coronary Artery Disease	Kidney Stones	High Cholesterol
Emphysema	Heart Attack	High Blood Pressure	Other

Do you use alcohol? Yes No	How much?
Do you smoke? Yes No	How much?
Notes/Comments:
Hospitalization/Surgery History
Please list any significant family medical problems:
Previous hospitalization or surgery:
Medications If you are currently taking any medications, please list them below, including dosage.

Drug Allergies List any drug allergies below.

Review of Systems Please check any that apply.
Constitutional	Respiratory	Neurologic	Gynecologic
Fever	Cough	Dizziness	Number of pregnancies
Weight loss	Asthma	Paralysis	Number of children
Lethargy	Wheezing	Seizures	Breast Cancer
Hot flashes	Pneumonia	Stroke	Genitourinary
Childhood Diseases	Immune	TIA	Kidney Stones
Rheumatic Fever	Allergies	Tremor	Kidney Infection
Mumps	Hay Fever	Balance problem	Bladder Infection
Asthma	Recurrent fever	Hematology	STDs
Eyes	HIV	Anemia	Impotence
Glasses	Musculoskeletal	Bleeding disorder	Urine Leakage
Contacts	Arthritis	Slow healing	Prostate Infection
Blurred vision	Muscle weakness	Bruising	BPH
Blindness	Back Pain	Gastrointestinal	Kidney Disease
ENT	Psychological	Diarrhea	Other:
Nosebleeds	Depression	Constipation	Problem with anesthesia
Speech problems	Nervousness	Nausea-Vomiting	Other comments:
Hearing loss	Anxiety	Weight loss
Cardiac	Insomnia	Abdominal pain
Chest pain	Endocrine	Reflux Disease
Shortness of breath	Parathyroidism	Hepatitis
Palpitations	Hypoglycemia	Liver Disease
Arrhythmia	Thyroid Disease
High blood pressure	Diabetes
To print, Click here or choose "File" then "Print" from your browser's menu.

4223 Richmond ● Houston, Texas 77027
(713) 351-0630